ORIGINAL ARTICLE

Delivery recommendations for pregnant females with risk

factors for rhegmatogenous retinal detachment
Hannah Chiu, MD,* Donna Steele, MD, FRCSC,, Chryssa McAlister, MD, FRCSC,*
Wai-Ching Lam, MD, FRCSC*,
ABSTRACT RSUM
Objective: High-risk pathologies for rhegmatogenous retinal detachment (RRD) in otherwise healthy pregnant females are not
contraindications for spontaneous vaginal delivery. However, 74% of European obstetrician-gynecologist (OBGYN) respondents in
2008 recommended operative delivery for females at risk for RRD. This discrepancy is likely due to an older study suggesting a causal
relation between Valsalva-like manoeuvres and RRD. The purpose of this study is to determine current delivery recommendations for
healthy pregnant females with high-risk pathologies for RRD among Canadian ophthalmologists and OBGYNs.
Methods: Anonymous prospective cross-sectional survey sent via electronic link in 2013. 2 test of proportions was used to
compare delivery recommendations between the 2 specialties. Multinomial logistic regression was used to identify predictors for
recommendations.
Results: A total of 356 participants responded including 92 ophthalmologists and 27 trainees, and 185 OBGYNs and 52 trainees.
For healthy pregnant females with previously treated retinal hole/tear or treated RRD, significantly more OBGYNs recommended
cesarean section and significantly more ophthalmologists recommended spontaneous vaginal delivery. Length of practice and
type of practice setting were significant predictors among obstetricians in their delivery recommendations.
Conclusions: This study is the first to include obstetricians, ophthalmologists, and their trainees in a survey of the recommended mode
of delivery for pregnant females with risk factors of RRD. Our results suggest that obstetricians concerned about potential RRD in
pregnant patients may be unnecessarily recommending operative management. Educational sessions on the risk for RRD with
spontaneous vaginal delivery may reconcile the current differences in recommendations between ophthalmologists and obstetricians.

Contexte : Le risque lev de dcollement de rtine rhegmatogne (DRR) chez les femmes enceintes en bonne sant n'est pas une
contre-indication l'accouchement vaginal spontan. Toutefois, 74 % des obsttriciens-gyncologues europens rpondants en
2008 ont recommand un accouchement par csarienne aux femmes risque de DRR. Cette incohrence est vraisemblablement
due une ancienne tude qui indiquait un rapport de cause effet entre les mouvements apparents aux manuvres de
Valsalva et le DRR. L'objectif de cette tude vise dterminer les recommandations actuelles des ophtalmologistes et celles des
obsttriciens-gyncologues du Canada aux femmes enceintes en sant risque lev de DRR.
Mthodes : Enqute transversale prospective anonyme envoye par lien lectronique en 2013. Utilisation du test du chi carr des
proportions pour comparer les recommandations d'accouchement entre les deux spcialits, et de la rgression logistique
multinomiale pour dterminer les variables explicatives des recommandations.
Rsultats : 356 participants ont rpondu l'enqute, dont 92 ophtalmologistes, 27 rsidents en ophtalmologie, 185 obsttriciens-
gyncologues et 52 rsidents en obsttrique-gyncologie. Aux femmes enceintes en sant ayant dj t traites pour un trou
rtinien, une dchirure de la rtine ou un DRR, un nombre significativement plus lev d'obsttriciens-gyncologues ont
recommand l'accouchement par csarienne, tandis qu'un nombre significativement plus lev d'ophtalmologistes ont
recommand l'accouchement vaginal spontan. Le nombre d'annes d'exercice et le type d'exercice sont des variables
explicatives importantes des recommandations des obsttriciens.
Conclusions : Cette enqute est la premire inclure des obsttriciens, des ophtalmologistes et leurs rsidents respectifs dans un
mme sondage sur le type d'accouchement recommand pour les femmes enceintes risque de DRR. Nos rsultats montrent
que les obsttriciens inquiets du risque de DRR chez leurs patientes pourraient recommander inutilement la csarienne. Des
sances de formation sur les risques associs au DRR l'accouchement vaginal spontan pourraient attnuer l'cart actuel entre
les recommandations des ophtalmologistes et celles des obsttriciens.

Retinal detachment is a vision-threatening condition. detachment with different pathophysiologic mecha-

Retinal detachments are rhegmatogenous when caused
by a retinal break, allowing uid from the vitreous cavity
into the subretinal space. Retinal detachments caused by
systemic vascular disorders seen in pregnancy such as pre-
eclampsia/eclampsia are known as exudative retinal
nisms.1,2 Risk factors for rhegmatogenous retinal detach-
ment (RRD) include high myopia that is usually dened
as greater than 6.00 D, existing retinal breaks or holes, and
previous retinal detachment.3 In the past, RRD was
theorized to be inuenced by Valsalva-like manoeuvres

From the *Department of Ophthalmology and Vision Sciences; Depart-
ment of Obstetrics and Gynecology, University of Toronto; Department
of Obstetrics and Gynecology, St. Michaels Hospital; and Department
of Ophthalmology, University Health Network, Toronto Western
Hospital, Toronto, Ont.
Presented as oral presentation (Retina) at Canadian Ophthalmological
Society Annual Meeting, June 4-7, 2014, Halifax, Nova Scotia
Correspondence to Wai-Ching Lam, MD, The Toronto Western
Hospital, 399 Bathurst Street, East Wing 6-432, Toronto ON M5T2S8;
waiching.lam@utoronto.ca
Can J Ophthalmol 2015;50:1118
0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological
Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2014.10.015

Originally received Apr. 19, 2014. Final revision Oct. 8, 2014. Accepted
Oct. 28, 2014

CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015 11

Delivery recommendations for pregnant femalesChiu et al.

during the second stage of labour.4 However, this theory
has long fallen out of favour because of increased knowl-
edge on the properties of the vitreous and its interactions
with the retina.
Current evidence suggests that normal deliveries are not
contraindicated in healthy pregnant females with RRD risk
factors.57 However, in a 2008 survey of obstetricians attend-
ing the 20th European Congress of Obstetrics and Gynaecol-
ogy, 74% recommended assisted delivery (either cesarean
section, forceps, or vacuum delivery) for pregnant females
with risk factors for RRD.8 Another study surveying obste-
tricians practicing in the West Midlands Health Region,
United Kingdom, demonstrated that 32 of 66 respondents
would consider previous RRD as an indication for cesarean
section.9 The primary purpose of this study was to delineate
current delivery recommendations for healthy pregnant
females with high-risk pathologies for RRD among Canadian
ophthalmologists, obstetricians, and the trainees of respective
specialties. The secondary purpose is to identify any predictors
for recommendation patterns.
METHODS
Ophthalmological Society and the Society of Obstetricians
and Gynecologists of Canada via the respective administra-
tors of each society. Condentiality was achieved through
enhanced SSL encryption using Google Questionnaire.
Anonymity was maintained with a unique numerical iden-
tier for data analysis, and data were password protected.
The consent form was written in both languages; however,
participants were asked to complete only an English version
of the questionnaire. The questionnaire consisted of 7 dem-
ographic questions (sex, specialty practicing or training in,
level of training, number of years in practice, subspecialty [if
applicable], province of practice or training, and practice
setting [academic, community, or both]). The rest of the
questionnaire is summarized in Figure 1. The survey was
open between June and December 2013, and an email
reminder was sent once. 2 test of proportions was used to
compare delivery recommendations between the 2 specialties
and between specialists and trainees within the respective
specialties. Logistic regression was used to identify predictors
for recommendations of surgical intervention (cesarean
section or instrumental delivery). Statistically signicant level
was set at p o 0.05.

A prospective cross-sectional survey was conducted. The RESULTS

study received approval from the Institutional Review Ethics
Board. An email with a link to an anonymous online A total of 356 participants responded including 92
questionnaire was distributed to both English- and French- ophthalmologists and 27 trainees (N 801 surveyed), and
speaking actively registered members of the Canadian 185 obstetricians-gynecologists (OBGYNs) and 52 trainees

1. Which of the following labour management would you recommend for an otherwise healthy
pregnant woman who is a high myope and who have a previously treated retinal hole/tear:

a. Cesarean section
b. Instrumental delivery
c. Spontaneous vaginal delivery
d. Do not know
2. Which of the following labour management would you recommend for an otherwise healthy
pregnant woman who is a high myope and had a previously treated retinal detachment?

a. Cesarean section
b. Instrumental delivery
c. Spontaneous vaginal delivery
d. Do not know
3. Please give an explanation for your decision above:
a. Standard of care
b. Practice guidelines
c. Research Studies
d. Preceptors opinion
e. Other _____________
4. (For obstetrics/gynaecology) When would you refer a patient to an ophthalmologist for
consultation with regards to labour management (select all that applies)?
a. High myope
b. Retinal tear/hole
c. Retinal detachment
d. Dont know
5. Have you had a patient develop a retinal detachment following delivery?
a. Yes
b. No
6. If you answered yes to the question above, what was the reason why?

Fig. 1 Delivery Recommendations for Healthy Pregnant Women Questionnaire.

12 CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015

 Delivery recommendations for pregnant femalesChiu et al.

Table 1Demographic characteristics of respondents (N 819 surveyed). The response rate was 15% for
OBGYN Ophthalmology ophthalmology and 29% for obstetrics/gynecology. Table 1
Respondents, n (females) summarizes demographic characteristics of respondents.
Trainees 52 (47) 27 (9)
Staff 185 (117) 92 (24)
There were statistically signicant differences between
Trainees delivery recommendations among specialties. Figure 2
Level of training (postgraduate year) summarizes respondents choice of recommendations for
1 6 0
2 9 2 healthy pregnant females with previously treated retinal
3 10 8 holes/tears. Obstetricians were more likely to recommend
4 15 10
5 12 5
instrumental delivery or cesarean section (34%), and
Residency program location ophthalmologists were more like to recommend sponta-
British Columbia 0 1 neous vaginal delivery (58%; p 0.001). This pattern of
Alberta 10 4
Saskatchewan 1 1 recommendation was similar for healthy pregnant females
Manitoba 1 1 with previously treated retinal detachment as summarized
Ontario 33 12
Quebec 6 7
in Figure 3, where 57% of obstetricians recommended
New Brunswick 1 N/A instrumental delivery or cesarean section compared with
Nova Scotia 0 1 68% of ophthalmologists recommending spontaneous
PEI N/A N/A
Newfoundland 0 N/A vaginal delivery (p o 0.001).
Specialists Among the trainees, the most common recommenda-
Median length in practice, yr (range) 13 (137) 14 (135)
Practice locations
tion for healthy pregnant females with a previously treated
British Columbia 26 10 retinal hole/tear was spontaneous vaginal delivery for
Alberta 23 11 ophthalmology residents (59%); however, signicantly
Saskatchewan 6 3
Manitoba 1 0
more OBGYN residents did not know what the recom-
Ontario 88 36 mendations should be (58%; p 0.008), as summarized
Quebec 31 15
in Figure 4. For healthy pregnant females with previously
New Brunswick 4 0
Nova Scotia 2 9 treated retinal detachment, the most common response for
PEI 0 2 both groups of trainees was do not know followed by
Newfoundland 1 1
Territories 1 0
spontaneous vaginal delivery for ophthalmology residents
Practice setting and cesarean section for OBGYN residents (p 0.04), as
Academic 82 24
summarized in Figure 5. There were no signicant
Community 64 38
Both 29 30 recommendation differences among the junior trainees
Type of practice (PGY1 3) and senior trainees (PGY4 5) for both
General 134 57
Subspecialty 51 35
specialties (p 0.13). There were no statistically signi-
OBGYN subspecialties cant differences between the specialists and the trainees in
Gyn-oncology 2 the respective specialties in the recommendation patterns.
Maternal fetal medicine 34
Reproductive endocrinology and infertility 15 Figures 6 and 7 summarize the reasons why respondents
Ophthalmology subspecialties and trainee respondents selected their recommendations,
Anterior segment
Glaucoma
4
10
respectively. For Other, the most common response for
Medical retina 13 obstetricians was would refer to an ophthalmologist and
Neuro-ophthalmology/strabismus 2 would refer to a subspecialist for ophthalmologists.
Oculoplastics 3
Pediatric ophthalmology 4 There was no statistical signicance in either groups
Vitreoretinal Surgery 22 responses (p 0.80 and p 0.44, respectively).
Recommendations

Do not know

SVD

Ophthalmology
Instrumental Delivery*
OBGYN
CS

0 10 20 30 40 50 60 70
Percentage of respondents

Fig. 2 Respondents delivery recommendations for a healthy pregnant woman with previously treated retinal holes/tears.
*Instrumental delivery represents forceps or vacuum delivery. CS, cesarean section; OBGYN, obstetrician/gynecologist; SVD,
spontaneous vaginal delivery.

CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015 13

Delivery recommendations for pregnant femalesChiu et al.

Recommendations
Do not know

SVD

Instrumental Delivery Ophthalmology

OBGYN
CS

0 10 20 30 40 50 60 70 80
Percentage of respondents

Fig. 3 Respondents delivery recommendations for a healthy pregnant woman with previously treated retinal detachment.
CS, cesarean section; OBGYN, obstetrician/gynecologist; SVD, spontaneous vaginal delivery.

Do not know
Recommendations

Instrumental Delivery

Ophthalmology trainees
SVD
OBGYN trainees

CS

0 10 20 30 40 50 60 70
Percentage of respondents

Fig. 4 Trainee respondents delivery recommendations for a healthy pregnant woman with previously treated retinal holes/
tears. CS, cesarean section; OBGYN, obstetrician/gynecologist; SVD, spontaneous vaginal delivery.

For respondents who were either obstetricians or
obstetrics/gynecology residents, they were asked to select
1 or more risk factors in a healthy pregnant woman that
would prompt a referral to an ophthalmologist for delivery
recommendations. No statistically signicant differences
were found between the 2 groups (p 0.8). Figure 8
summarizes the responses for referral criteria. For the
majority of obstetricians and their trainees, previous
history of retinal tear or holes would prompt a referral
to an ophthalmologist for assessment. Less than 20% of
either group would refer to an ophthalmologist if a patient
had high myopia alone. Fifteen percent of obstetricians
and 25% of obstetrics trainees did not know when they
would refer to an ophthalmologist.
Among practicing OBGYNs, signicant predictors of
recommending cesarean section or instrumental delivery for
healthy pregnant females with previously treated retinal
detachment include type of practice setting and length of
practice. Those practicing in academic settings were less likely
to recommend surgical intervention at the time of delivery
(odds ratio [OR] 0.39, p 0.03). Those with more years of
practice were more likely to recommend instrumental
delivery or cesarean section (OR 1.05, p 0.04). Type of
practice setting was also a signicant predictor in healthy
pregnant females with previously treated retinal hole, where
those in academic setting were less likely to recommend
surgical intervention at the time of delivery (OR 0.5, p
0.03). Among practicing ophthalmologists, there were no
signicant predictors for surgical intervention at the time of
delivery. Table 2 summarizes these data.
Twelve respondents (n 356) reported having a
patient with retinal detachment after delivery. When asked

Do not know
Recommendations

Instrumental Delivery

Ophthalmology trainees
SVD
OBGYN trainees
CS

0 10 20 30 40 50
Percentage of respondents

Fig. 5 Trainee respondents delivery recommendations for a healthy pregnant woman with previously treated retinal
detachment. CS, cesarean section; OBGYN, obstetrician/gynecologist; SVD, spontaneous vaginal delivery.

14 CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015

 Delivery recommendations for pregnant femalesChiu et al.
Fig. 6 Reasons for delivery recommendations.
for the cause of the retinal detachment, 6 identied
detachments caused by severe pre-eclampsia, 5 identied
an unknown cause, and 1 identied the cause as pro-
longed second stage of labour.
DISCUSSION
Thirty-four percent of Canadian OBGYNs surveyed
recommend cesarean section or instrumental delivery at
the time of delivery in healthy pregnant females with risk
factors for RRD. In comparison, only 4% of Canadian
ophthalmologists surveyed recommended intervention at
the time of delivery. These results are similar amongst
trainees, where 33% of Canadian obstetrics/gynecology
residents would recommend intervention in patients with
previously treated retinal hole/tear compared with 4% of
ophthalmology residents. However, in patients with pre-
viously treated retinal detachment, there was a more
similar response among the trainees; although spontaneous
vaginal delivery remains the more frequent recommenda-
tion among ophthalmology residents, 26% recommended
cesarean section, indicating there is a greater level of
confusion even among ophthalmology trainees when the
perceived risk for RRD may be greater compared with a
treated retinal hole or tear.
Compared with previous studies5,8,9 that indicate that
between 48% and 75% of obstetrician respondents would
consider intervention in healthy females with previous
retinal detachment during delivery, our obstetrics/gynecol-
ogy cohort was less likely to recommend surgical inter-
vention (36%). The difference may be a reection of
geographic preferences as previous studies were conducted
in United Kingdom and at the European Congress of
Obstetrician and Gynaecology; alternatively, because our
study cohort is more recent, current training may have
decreased the prevalence of perceived risk that Valsalva-
like manoeuvre during spontaneous vaginal delivery could
cause a retinal detachment. Twelve respondents had a
patient who experienced retinal detachment, in which
CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015 15
Delivery recommendations for pregnant femalesChiu et al.
Fig. 7 Trainees reasons for delivery recommendations.
50% were due to pre-eclampsia, an exudative retinal
detachment from elevated blood pressure. Exudative
retinal detachments occur secondary to shifts in uid into
the subretinal space without retinal tear and, therefore,
have a different mechanism and treatment than RRDs. In
addition, the mode of delivery will not have any effect on
the outcome of the exudative retinal detachment that will
usually resolve spontaneously after delivery. This confu-
sion in terminology may play a signicant role in the false
perception that Valsalva-like manoeuvres during vaginal
delivery can lead to RRD.
In a study from 2008, 58% of obstetrician respondents
selected personal opinion of standard of care as the reason
for intervention during the second stage of labour.8 In our
cohort, 44% of obstetricians and 55% of ophthalmologists
also indicated standard of care as the reason for their
recommendations, followed by research (12%) and prac-
tice guidelines (4%). These results suggest that despite the
differences in recommendations between the 2 specialties,
16 CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015
the rationale for these recommendations rests largely on
perceived standard of care rather than body of evidence or
guidelines. This trend is also observed among trainees of
both specialties, where preceptors opinion was the most
frequent response (30% and 31%).
When evaluating referral patterns, it appears that most
OBGYNs and trainees consider previous history of treat-
ment of retinal detachment (85% and 75%, respectively)
requiring an ophthalmology opinion, followed by retinal
hole or tear (75% and 50%, respectively), but are less
concerned about high myopia alone. This trend is
reinforced by the pattern of risk assessment in a study
by Elsherbiny et al.,9 where the majority of the obstetri-
cians considered previous retinal detachment high risk,
previous laser treatment of retinal tear moderate risk, and
high myopia low risk.
Our study showed that obstetrician respondents prac-
ticing in an academic setting are signicantly less likely to
recommend intervention at the time of delivery in patients
 Delivery recommendations for pregnant femalesChiu et al.

Fig. 8 Risk factors for rhegmatogenous retinal detachment that would prompt a referral to an ophthalmologist.

with previously treated retinal detachment or retinal holes/
tears. Possible explanations for this nding include a
greater exposure to the ophthalmology department or
greater exposure to rounds that update on clinical practice.
Interestingly, in the hypothetical setting where healthy
pregnant females have had a previously RRD, obstetricians
who had practiced for longer were signicantly more likely
to recommend intervention (OR 1.05, p 0.04). It was
not a signicant predictor in the study by Papamichael
et al.,8 where they found that those who practiced more
than 20 years were not signicantly more likely to
recommend surgical intervention.

Table 2Predictors of recommending cesarean section or instrumental delivery for healthy pregnant females

OBGYN Ophthalmology

Odds Ratio (95% CI) p Odds Ratio (95% CI) p

Previously treated retinal detachment
Type of practice setting* 0.39 (0.200.73) 0.03 0.30 (0.061.40) 0.08
Length of practice (yr) 1.05 (1.0021.103) 0.04 1.00 (0.921.09) 0.92
Subspecialization 0.70 (0.212.36) 0.56 0.24 (0.041.56) 0.13
Previously treated retinal hole
Type of practice setting* 0.50 (0.200.77) 0.03 0.15 (0.011.59) 0.11
Length of practice (yr) 1.02 (0.961.07) 0.53 1.01 (0.971.05) 0.63
Subspecialization 1.40 (0.484.07) 0.59 0.25 (0.032.4) 0.23

*Type of practice setting includes academic, community, both.

CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015 17

Delivery recommendations for pregnant femalesChiu et al.
Our study is limited by the low response rates (29%
of OBGYNs surveyed, 15% of ophthalmologists sur-
veyed). A possible reason for differences in response
rates between the 2 specialties may be that among
ophthalmologists the recommendations regarding cesar-
ean section in healthy pregnant females at risk for RRD
are not controversial, and therefore there was less
interest in participating. The survey method through
electronic communications may have resulted in email
fatigue and be a factor in low response rates among
both specialties.10 It is also a cross section of current
opinion of practicing ophthalmologists and OBGYNs,
and do not reect rates of cesarean section or instru-
mental delivery solely for the reason of ophthalmologic
risks.
This is the rst survey of obstetricians, ophthalmol-
ogists, and their trainees, on the recommended mode of
delivery for pregnant females with risk factors of RRD.
Our results suggest that OBGYNs concerned about
potential RRD in pregnant patients may be unnecessa-
rily recommending operative management; furthermore,
confusion about risks for RRDs with Valsalva-like
manoeuvres exists among trainees in both specialties.
Educational sessions on the risk for RRD with sponta-
neous vaginal delivery and the differences in patho-
physiology compared with exudative retinal detachment
that involves managing the underlying systemic disorder
may help clarify the appropriate recommendations for
18 CAN J OPHTHALMOL VOL. 50, NO. 1, FEBRUARY 2015
delivery options in pregnant patients with risk factors
of RRD.
Disclosure: The authors have no proprietary or commercial
interest in any materials discussed in this article.
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